‘Be prepared to negotiate’ with patients when choosing osteoporosis treatment

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DESTIN, Fla. — Individualized treatment for osteoporosis calls for a keen understanding of the patient’s frame of mind, according to a speaker at the Congress of Clinical Rheumatology East.

“Understand your patient’s mindset before making a recommendation,” E. Michael Lewiecki, MD, clinical professor of medicine at the University of New Mexico Health Sciences Center, and director of the New Mexico Clinical Research and Osteoporosis Center, told attendees. “Be prepared to negotiate when the patient does not agree to your recommendation.”

E. Michael Lewiecki, MD, speaks at CCR East 2024.

“Understand your patient’s mindset before making a recommendation,” L. Michael Lewiecki, MD, told attendees. “Be prepared to negotiate when the patient does not agree to your recommendation.” Image: Justin Cooper | Healio

According to Lewiecki, a key part of the osteoporosis treatment path — from fracture risk assessment to evaluation, discussion, choice of intervention and follow-up — is the conversation about treatment choice and possible side effects.

“The patients have been reading in magazines and newspapers about horrendous, rare, but possible, side effects of osteoporosis medicine,” he said. “They have to understand the FDA has a different use of the English language than you and I.”

Lewiecki added that “things that are called side effects” often have not actually been established to be caused by the drug. For example, the package insert for Prolia (denosumab, Amgen) lists back pain and high cholesterol as the most common side effects, potentially warding off patients who already face back pain and high cholesterol, he said.

“Nobody believes there’s a causal relationship between those occurrences,” Lewiecki said. “But it happens that, numerically, there are a few more people in the Prolia group than the placebo group in the clinical trial that had back pain and high cholesterol, so in the wisdom of the FDA, those things have to be listed as side effects.”

One possible way around this issue could be to not tell a patient about those side effects at all — albeit with the patient’s prior consent, he added.

“There’s actually some psychiatrists that have developed a strategy where you reach an agreement with the patient up front that you will not tell the patient about incredibly rare possible side effects, so they don’t have to worry about it,” Lewiecki said. “I’ve never tried to do that, but it might work.”

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